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patientstories

Palliative Care: A Day in the Life

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“Life is pleasant; Death is peaceful. It’s the transition that is troublesome”- Isaac Asimov

Palliative care is a field of medicine that focuses on an individual’s and family’s quality of life as they suffer from a chronic illness. It involves ensuring the individual is knowledgeable about their disease process, has all of the resources they need to succeed, and can ultimately end with Hospice care.

Palliative care candidates are those who suffer from chronic illness such as heart failure, COPD, multiple sclerosis, cancer, etc. Hospice is a subset of the umbrella of palliative care, but not all palliative services involve hospice.

Palliative care enables individuals to have the best quality of life for their illness. With the knowledge they need to succeed, individuals with palliative care often live longer, go to the hospital less, and have a higher life satisfaction.

The team involves MDs, RNs, social workers, case managers, and more. They all work together to provide an extra layer of support and listening ears. The team may assist with arranging resources, pain control relating to the illness, advanced care planning, end of life wishes, among many others things.

Today, I got the opportunity to witness a beautiful conversation between a palliative care nurse and a wife of her very ill husband at the bedside in the ICU. The RN opened the conversation to the wife and the wife had unrealistic beliefs regarding her husband’s medical condition. The RN was able to answer questions regarding his diagnosis/prognosis, provide options, pray, and truly listen to the wife’s concerns. Here are a few questions/concerns the wife had that were answered:

  • What will happen if we turn off the machines?
  • Will the doctor say, ‘I told you so’?
  • Will he gasp for air?
  • How will I live without him?
  • I never lost hope in God. This just isn’t in his plan and that is so hard.
  • How do I tell my 3.5 year old granddaughter that papa is not coming home?
  • How do I call and start this conversation with my family?
  • He isn’t getting any better, but my heart hurts so much.
  • I know he wouldn’t want to be on life support, but how do I know when to stop it?

The Palliative Care team gives families and individuals the opportunity to discuss their concerns in a safe environment and the support when they may not even realize they need it. It is a heartbreaking field to be in, but it is truly a calling and the opportunity to witness this interaction was such a blessing.

Do you have any patients or family members that may benefit from palliative care?

Until next shift,

Shania

Clots, Codes, and COVID

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A 50 y/o COVID positive male is admitted to the med-Surg floor on 4L BNC. Shortly after arriving, the patient turned blue and became hypoxic. The rapid response team was called and the patient was immediately taken to get a CT scan with PE protocol to assess for a clot in the lung. The patient had to be placed on a bipap for transfer to radiology. This involved a respiratory therapist, ICU nurse, charge nurse, and a primary RN. I was instructed to carry 2 extra oxygen tanks as the patient was depleting the existing tanks rather quickly. As we arrive at radiology, the current 2 tanks are emptied, and I had to run to another department to grab additional back ups.

Once the CT was completed, we moved straight to the cardiac cath lab. There, they told the patient that it was necessary to perform a rapid sequence intubation and subsequent transfer to the ICU after all imaging was done. The pt became tearful and stated he could not breathe throughout the full 2 hour code.

Covid has been such a strange virus and we continue to learn more at each patient encounter. Prior to this admission, the patient was healthy with minimal preexisting conditions. The last night shift I worked, I happened to walk into his room to fix a beeping IV and was so excited to see this man awake, alert, and talking to me.

He told me that he had several clots throughout his entire body.. his heart, lungs, and his legs. He stated that he had coded twice in the ICU. He was covered in bruises and complaining of severe generalized pain. He was placed on a heparin drip to prevent any further clotting. I was so excited to see how “good” he looked and he was so grateful to be alive.

Covid is no joke and can change a life in seconds. This man may still be on oxygen, be quarantined in the hospital through Christmas, be covered in bruises, and suffering from generalized pain; however, he is alive. This is another humbling reminder to always count my blessings.

Until next shift,

Shania

If your leg hurts, don’t wish to cut it off

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A woman in her 50s was treated in a burn center and brought to our facility for continued medical treatment of her delayed healing leg. It looked like she got her lower leg stuck underneath a lawn mower, when it was actually due to a heating pad. Surgery was done to clean out the wound and remove dead tissue. External fixation was placed to ensure proper placement. After 3 months of hospitalization, the patient decided to get it amputated due to the severe pain. She was also aware that even if the leg healed, it would take extensive rehab to ever walk again.

This scenario justifies the importance of pain management and education. Pain is now seen as the 4th vital sign. We ask everyone if they are in pain and will medicate the said pain if present. Many patients immediately expect narcotics and opioids to be the only relief for their pain. Educating on nonopioid or no nonpharmacological pain management is crucial to effectively treat pain. These modalities include NSAIDS, ice/heat therapy, massage, imagery, and movement among others.

This patient had several moderate dose narcotics available as well as IV ketoralac/ Toradol. The only medication that was actually effectively for a long duration was the Toradol.

Toradol is classified as an NSAID and can only be given up to 5 days to prevent GI bleeding and kidney issues. However, with it being an anti inflammatory, this medication was greatly effective for a recently amputated leg. The patient was aware of that and only requested the Toradol for her pain. Education is key.

Aside from the pain management of this woman, her positive outlook on her situation is also what leads to positive healing. She repeatedly stated how God will bring her through any situation she faces. She was confident that this was in her plan and was determined to do anything it took to heal her body.

We actually developed a good rapport after realizing we both favor a particular pastor and both plan on attending his church after the pandemic.

It is important to not simply treat the patient, but to try and communicate with them as human beings. You never know who is in that bed.

When I was going off shift, she reminded me that if my leg was ever hurting, not to wish to cut it off.. I plan to take that advice to heart.

Until next shift,

Shania

If I could only have half of the faith… angels in disguise

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50 y/o female with multiple myeloma and leukemia presents to the ER for a fever… a medical emergency in one receiving chemotherapy due to myelosuppression.

She has been in and out of hospitals to receive chemo and then be readmitted for the side effects of cancer.

I walk into the room and she is diffusing essential oils, she is riding around the hall and her room in her wheelchair, she is cracking jokes, she is laughing, and has the biggest smile on her face, and she asks about everyone’s personal lives when they walk into the room. I have never met someone with as much hope, faith, joy, and someone who as closely resembles Jesus as this precious woman.

She told me that Jesus will put angels in your path and I was one of hers. I can say that Jesus put her as my angel during my past three, challenging shifts.

Covid has brought a much higher acuity census to the caseload and this week has been stressful, challenging, and draining.

Her joy and optimism brought the just needed light into my week. I fortunately was able to sit with her for quite some time as I administered blood transfusions.

The highlight of my entire nursing career thus far was when she asked to go to the main lobby to play the grand piano. I was able to wheel her down in her wheelchair with her IV pole, mask, and lots of hand sanitizer to go sit and play her joyful noise. I couldn’t help but become teary eyed.

Even through everything that she was facing, she continued to minister to others and bring such joy into their lives. If I have half of the faith of this Godly woman, I will be okay.

It is a reminder that even on the toughest days; take a deep breath and trust that God has your back.

Until next shift,

Shania

Things nursing school does not teach you

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Even after the 2-4 years of intense studying that is required to become a registered nurse, it takes about a year working full-time to feel comfortable in the new leadership position. There is anywhere between 6-12 weeks of orientation with an experienced preceptor, as well as facility-required courses and classes. Nursing school teaches the disease process and basic assessment techniques, but does not prepare the student for the actual nursing role. Below is a brief list of things nursing school does not teach…

  1. Nurses have autonomy. Nurses see the patients 12 hours/day while doctors view the patient for at most 30 minutes. Nurses are in charge of reporting assessment changes, communicating critical lab values, ordering interventions per nursing protocols, among many other things. Textbooks ensure a doctor’s order for everything, when in reality nurses often drive these orders.
  2. Nurses do not provide “total care.” In many clinical rotations that I have had, we were assigned one patient and required to complete the assessments, baths, vital signs, and administer all medications. These patient encounters were unrealistic compared with the actual routine of a bedside nurse. Yes, it is in the scope of practice to perform all of these things, however, there is not enough time in the shift to perform all of these interventions for all 5-6 patients. It is extremely important to delegate to nursing assistants and to assist them when able.
  3. The Davis Drug book is not your best friend. It is much easier and acceptable to use online drug resources such as Micromedex or Medscape. Many MARs actually have reference information for drug administration directly on the administration wizard.
  4. You will not chart in real time. It is okay to back-time assessments. It is impossible to chart as you complete nursing tasks while ensuring all patients are cared for in a timely manner.
  5. Over 50% of a shift is behind a computer. This was the biggest challenge for me when transitioning from a CNA to an RN. It is frustrating to have so little hands-on time with the patients, while spending a lot of time reviewing orders, charting, on the phone, etc.
  6. You do not always have to “call” the doctor. Many facilities have a direct messaging system to relay non-emergent information, rather than calling the doctor for every request.
  7. Find out what advancement opportunities a facility offers. Anything from tuition reimbursement, mentorship programs, and certification incentives…
  8. You have to be creative. This applies to many things such as finding new ways to use nursing supplies, working with only two hands, convincing the confused patient to stay in the bed, or communicating effectively with difficult families. One of the funnier moments of creativity was one a nurse used a syringe of normal saline to stop a “seizure” a patient was apparently having. She said this injection of “Normasaline” will stop the seizure, and miraculously it worked!
  9. The burden of health care is real. Every shift, there will be a patient who is medically cleared for discharge, however is waiting on insurance approval to go to rehab or a skilled nursing facility. A patient is noncompliant with medications because they cannot afford them.
  10. Use free time wisely. Any extra time should be spent helping out other nurses, researching disease processes, updating report cards, or studying for continuing education. That extra study time will be appreciated during the busy shifts when you are trying to find enough time to pee.
  11. Having a patient leave AMA (against medical advice) is probably for your benefit. Don’t take it to heart.
  12. Even the best, most experienced nurse will get yelled at by a patient, family member, or doctor. It is okay.
  13. Always remain humble and ask questions.. just because you learned how to do something one way, does not mean that it is the best way.

Until next shift,

Shania

It’s called Chorea

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A man in his 70s with a history of diabetes mellitus and myasthenia gravis presents with severe, involuntary movements of both upper and lower extremities coupled with uncontrollable nausea, vomiting, and diarrhea. It looked like this man was having a never-ending grand-mal seizure while remaining conscious and not foaming from the mouth. He was brought into the ED after sustaining multiple falls while at home, and was treated with increased doses of Mestinon which caused the vomiting and diarrhea.. we tried to fix the movements, while causing fluid volume deficits.

Myasthenia gravis is a neuromuscular disorder that results in easy fatiguability of muscles, whereas this man was having excitability of all muscles. The neurologist coined these involuntary movements as chorea and attempted to treat with Olanzapine (antipsychotic), Keppra (antiseizure), and pyridostigmine/Mestinon (anti-myasthenia gravis) medications. The MD thought the chorea could potentially be caused by hyperglycemia (I have never heard of this as a cause), which was also a problem during this admission.

I do not know what the ultimate cause of the choreic movements was, but after sleep and medication therapy, the patient was discharged from the hospital with vastly reduced movements and was working with physical therapy the next day.

Until next shift,

Shania

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615-856-8181
shania@shanialynnvo.com